Provided by David Satcher, M.D., Ph.D.
Surgeon General of the United States of America
Chapter 3: Children and Mental Health
Developmental Psychopathology
Current Developmental Theory Applied to Child Mental Health and Illness
A number of central concepts and guiding assumptions underpin our current
understanding of children’s mental health and illness. These have been variously
defined by different investigators (Sroufe & Rutter, 1984; Cicchetti & Cohen,
1995; Jensen, 1998), but by and large these tenets are based on the premise that
psychopathology in childhood arises from the complex, multilayered interactions
of specific characteristics of the child (including biological, psychological,
and genetic factors), his or her environment (including parent, sibling, and
family relations, peer and neighborhood factors, school and community factors,
and the larger social-cultural context), and the specific manner in which these
factors interact with and shape each other over the course of development. Thus,
an understanding of a child’s particular history and past experiences (including
biologic events affecting brain development) is essential to unravel the why’s
and wherefore’s of a child’s particular behaviors, both normal and abnormal.
While this principle assumes developmental continuities, to the extent that
early experiences are“brought forward” into the current behavior, it is also
important to consider developmental discontinuities, where qualitative shifts in
the child’s biological, psychological, and social capacities may occur. These
may not be easily discerned or predicted ahead of time and may reflect the
emergence of new capacities (or incapacities) as the child’s psychological self,
brain, and social environment undergo significant reorganization.
A second precept underlying an adequate understanding of children’s mental
health and illness concerns the innate tendencies of the child to adapt to his
or her environment. This principle of adaptation incorporates and acknowledges
children’s “self-righting” and“self-organizing” tendencies; namely, that a child
within a given context naturally adapts (as much as possible) to a particular
ecological niche, or when necessary, modifies that niche to get needs met. When
environments themselves are highly disordered or pathological, children’s
adaptations to such settings may also be pathologic, especially when compared
with children’s behaviors within more healthy settings. This principle
underscores the likelihood that some (but not all)“pathologic” behavioral
syndromes might be best characterized as adaptive responses when the child or
adolescent encounters difficult or adverse circumstances. Notably, this ability
to adapt behaviorally is reflected at multiple levels, including the level of
brain and nervous system structures (sometimes called neuroplasticity).
A third consideration that guides both research-based and clinical approaches to
understanding child mental health and illness concerns the importance of age and
timing factors. For example, a behavior that may be quite normal at one age
(e.g., young children’s distress when separated from their primary caretaking
figure) can be an important symptom or indicator of mental illness at another
age. Similarly, stressors or risk factors may have no, little, or profound
impact, depending on the age at which they occur and whether they occur alone or
with other accumulated risk factors.
A fourth premise underpinning an adequate understanding of children’s mental
health and illness concerns the importance of the child’s context. Perhaps the
most important context for developing children is their caretaking environment.
Research with both humans and animals has demonstrated that gross disruptions in
this critical parameter have immediate and long-term effects, not just on the
young organism’s later social-emotional development but also on physical health,
long-term morbidity and mortality, later parenting practices, and even
behavioral outcomes of its offspring. Moreover, context may play a role in the
definition of what actually constitutes psychopathology or health. The same
behavior in one setting or culture might be acceptable and even“normative,”
whereas it may be seen as pathological in another.
Yet another principle central to understanding child mental health and illness
is that normal and abnormal developmental processes are often separated only by
differences of degree. Thus, supposed differences between normal and abnormal
behavior may be better understood by taking into account the differences in the
amount or degree of the particular behavior, or the degree of exposure to a
particular risk factor. Frequently, no sharp distinctions can be made.
The virtue of these developmental considerations when applied to children is
that (a) they enable a broader, more informed search for factors related to the
onset of, maintenance of, and recovery from abnormal forms of child behavior;
(b) they help move beyond static diagnostic terms that tend to reduce the
behaviors of a complex, developing, adapting, and feeling child to an
oversimplified diagnostic term; (c) they offer a new perspective on potential
targets for intervention, whether child-focused or directed toward environmental
or contextual factors; and (d) they highlight the possibility of important
timing considerations: windows of opportunity during a child’s development when
preventive or treatment interventions may be especially effective.
In the sections that follow, these considerations will help the reader
understand the important differences from chapters focusing principally on
adults, as well as the unique opportunities for intervention that occur because
of these differences.
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